Special consideration application form TA79 / TA930

Special consideration application form TA79 / TA930

Exceptional circumstances/Alternative assessment arrangements
Form No: TA79 / TA930
Last Revised: July 2025
Version: v8
Before submitting an application for special consideration on the grounds of exceptional circumstances or alternative assessment arrangements, applicants should ensure they have read and are familiar with the provisions of the ACEM Exceptional Circumstances and Special Consideration Policy (the Policy) and/or the Exceptional Circumstances and Special Consideration Policy: Examinations. Applications must be submitted within the timeframe(s) stipulated in the policy.
1. Applicant details
Applicant name*

First NameLast Name
ACEM ID*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
Please enter a valid phone number.
Email *
(Communication will usually be via email)
If it is not possible, due to the nature of the event(s) in question, for the individual requesting special consideration to submit the application, it may be submitted by the individual’s nominee.
Nominee name (If applicable)

First NameLast Name
Phone number

Area CodePhone Number

2. Application type
This application is for special consideration:*

On the Grounds of Exceptional Circumstances (Section 3, below)For Reasonable Adjustments to Assessment Arrangements (Section 4, below)
ACEM: Exceptional Circumstances and Special Consideration Policy TA930
3. Application on the Grounds of Exceptional Circumstances
Grounds on which this application is made (please select):*

Permanent and/or chronic illness, impairment or disability, including complications of pregnancyAcute medical conditions or serious illness or injuryCompassionate groundsSevere stress resulting from extreme hardship or traumaSignificant hardship as a result of a natural disaster (e.g. flood or bushfire)Other (Please specify):
Nature of Exceptional Circumstances

Pursuant to section 6 of the Exceptional Circumstances and Special Consideration Policy and/or section 5 of the Exceptional Circumstances and Special Consideration Policy – Examinations, please attach a letter detailing the nature of the circumstances and specifying in what way(s) those circumstances are considered to be ‘exceptional’ in that they hampered capacity to meet the requirement(s) to which this application relates or adversely affected performance in the assessment(s).
Letter attached?*

YesNo (if not attaching a letter, please ensure you include this information in the comment box ahead)
Supporting information/documents:

With reference to section 6.2 of the Exceptional Circumstances and Special Consideration Policy and/or section 5.2 (1) of the Exceptional Circumstances and Special Consideration Policy – Examinations, is any supporting information/documentation attached?
Supporting information/documents attached?*

YesNo
List any information/documentation attached in support of this application and the ground(s) on which it is made.
4. Application for Reasonable Adjustments to Assessment Arrangements
Grounds on which this application is made (please select):*

Permanent or chronic impairment or disabilityReligious observance requirements which do not permit participation in an assessment as a particular time or on a particular dayPregnancy or nursing an infant at the time of sitting an ACEM examinationDiagnosis of neurodiversity made by a practitioner accredited to perform such assessments and make diagnosesMedical groundsCompassionate grounds
Assessment / Examination details
Assessment / Examination for which reasonable adjustments are sought:*
Assessment / Examination date*
Location (if applicable, i.e. written exam)
With reference to section 6.2 of the Exceptional Circumstances and Special Consideration Policy and/or section 5.2 (1) of the Exceptional Circumstances and Special Consideration Policy – Examinations, list the information/documentation attached in support of this application and the ground(s) on which it is made.
Supporting information/documents attached?*

YesNoNo - Currently awaiting supporting documentation - will send to relevant ACEM team via email once acquired.
* Please note that any special consideration applications awaiting supporting documentation will not be progressed until the College receives all necessary documenetaion required as per the ACEM: Exceptional Circumstances and Special Consideration Policy TA930.
Diagnosis of neurodiversity*

Personal letter from trainee attachedEvidence of diagnosis attachedContemporaneous evidence of ongoing treatment / management attached
Permanent or chronic impairment or disability*

Personal letter from trainee attachedDetailed medical certificate / letter from current treating specialist attached
Religious observance or cultural requirements*

Personal letter from trainee attachedStatutory declaration attached
Pregnancy or nursing an infant*

Personal letter from trainee attachedMedical certificate / letter from current treating medical or midwife practitioner (pregnancy) or declaration signifying breastfeeding at date of examination (breastfeeding) attached
Medical grounds*

Personal letter from trainee attachedDetailed medical certificate / letter from current treating specialist attached
Compassionate grounds - select those relevant*

Personal letter from trainee attachedBereavement notice attachedMedical certificate / letter from current treating specialist (where illness is involved) attachedPolice incident report attachedStatutory declaration (stating relevant circumstances) attachedOther
Upload any supporting information/documents

Cancelof

Declaration
In submitting this form:
- I confirm that I have read the ACEM Exceptional Circumstances and Special Consideration Policy and/or Exceptional Circumstances and Special Consideration Policy – Examinations and agreed to abide by the terms and processes set out therein;
- I have provided all information relevant to my application with this form and acknowledge that failure to provide any and all relevant information my affect the outcome of my application; and
- I understand that my application will not be progressed until the applicable fee, if any, has been paid.
Signature of applicant*

Clear
Date*

Special consideration application form TA79 / TA930

1. Applicant details

2. Application type

3. Application on the Grounds of Exceptional Circumstances

4. Application for Reasonable Adjustments to Assessment Arrangements

Declaration

6. Submission

7. Payment of application fee